Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
5D
0E
1F
Potential for minimal harm
0A
0B
0C
April 27, 2026Complaint inspection · 3 citations
- J
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on staff interviews, record review, review of the facility documentation, and review of the facility's policy titled MDS (Minimum Data Set) - Care Plan, the facility failed to implement a person-centered, comprehensive care plan related to the administration of medication as ordered for one of nine residents (R) (R1) reviewed for a medication administration. Specifically, the facility administers Methotrexate 2.5 mg (milligram) once a day instead of once weekly, as ordered. As a result, R1 experienced medical complications requiring a transfer to an acute care hospital and expired on [DATE] due to Methotrexate toxicity. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. [...]
- J
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review, staff interviews, and the facility policy titled Pharmacy Services and Medication Regimen Review (MRR), the facility failed to ensure that one of nine residents (R) (R1) was free from an unnecessary medication related to an excessive dose of Methotrexate Sodium tablets. Specifically, the facility administers Methotrexate 2.5 mg (milligram) once a day instead of once weekly, as ordered. As a result, R1 experienced medical complications requiring a transfer to an acute care hospital and expired on [DATE] due to Methotrexate toxicity. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. [...]
- J
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review, staff interviews, and the facility policy titled Pharmacy Services and Medication Regimen Review (MRR), the facility failed to ensure that one of nine residents (R) (R1) was free from a significant medication error related to facility staff administering Methotrexate 2.5 mg (milligram) once a day instead of once weekly, as ordered. As a result, R1 experienced medical complications requiring a transfer to an acute care hospital and expired on [DATE] due to Methotrexate toxicity. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 4:27 pm. [...]
December 4, 2025Standard inspection · 0 citations
September 19, 2024Standard inspection, Complaint inspection · 3 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Urinary Catheter Care, the facility failed to ensure urinary catheter drainage bags were covered to protect the dignity of two of four sampled residents (R) (R71 and R94) with indwelling urinary catheters. This failure had the potential to diminish R71 and R94's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to implement care plan interventions for two of 48 sampled residents (R) (R94 and R66). This failure had the potential for R94 and R66 to not receive treatment and/or care according to their needs.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Oxygen Therapy, the facility failed to ensure that two of 48 sampled residents (R) (R94 and R66) were administered oxygen therapy in accordance with the physician orders. This failure had the potential to affect the necessary respiratory care and services that are in accordance with professional standards of practice.
April 27, 2023Standard inspection · 3 citations
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on observation, staff interviews, and review of facility policy titled, Infection Preventionist the facility failed to designate at least one qualified Infection Preventionist (IP), who is responsible for the facility's Infection Prevention, Control & Immunizations (IPCP).
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record review, staff interview, and review of the facility policy titled, MDS: OBRA Assessments the facility failed to develop a person-centered care plan related to oxygen use for one of three residents (R) (R#113). Specifically, the facility failed to ensure that a care plan was developed for R#113 pertaining to the prn use of oxygen therapy.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wrote2. Record review for R#159 revealed resident was admitted to the facility with the diagnoses not all inclusive of Pulmonary fibrosis, Malignant neoplasm, dependence on supplemental oxygen, shortness of breath, and chronic obstructive pulmonary disease. Review of resident physicians' orders revealed continuous oxygen at 3 liters per minute via nasal cannula. Review of Quarterly MDS assessment dated [DATE] section C0500 revealed a BIMS score of 15 indicating resident was cognitively intact. Section O (Special treatments) indicated the resident was receiving oxygen therapy during the seven day look back period for assessment. Observation on 4/25/2023 at 10:36 a.m. revealed R#159's oxygen tank filter dirty, nebulizer machine on floor uncovered, portable oxygen tank has an exposed nasal cannula. Observation on 4/26/2023 at 8:42 a.m. [...]
Fire safety inspections
21 fire safety citations on file: 7 on December 4, 2025, 2 on September 19, 2024, 12 on April 27, 2023.
Every fire safety citation21 citations
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · December 4, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · December 4, 2025 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · December 4, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 4, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · December 4, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · December 4, 2025 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · December 4, 2025 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · September 19, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 19, 2024 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · April 27, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 27, 2023 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 27, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 27, 2023 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · April 27, 2023 · Corrected (the home has a date of correction)
- D
Construct fire resistant interior walls.
K 331 · April 27, 2023 · Corrected (the home has a date of correction)
- D
Install properly constructed windows in hallway walls or doors.
K 364 · April 27, 2023 · Corrected (the home has a date of correction)
- D
Have properly sized and located compartments to protect residents from smoke.
K 371 · April 27, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · April 27, 2023 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of highly flammable decorations.
K 753 · April 27, 2023 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · April 27, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · April 27, 2023 · Corrected (the home has a date of correction)